CICO:

AWAGs approach
Dr David Lacquiere
Consultant Anaesthe5st
Abergavenny
AWAG Secretary

Disclaimer
These are the opinions of the AWAG
commiDee
They are no subs5tute for sound clinical
judgment but may assist the clinician
managing a CICO scenario
AWAG recommends anaesthe5sts undertake
regular CICO training*
* Contact david.lacquiere@wales.nhs.uk for more details

Objec5ves
Outline AWAGs posi5on on management of
CICO scenario in Wales
Describe dierences + similari5es between
our recommenda5ons and that of DAS1
Explain why we believe our approach has
advantages
Signpost prac55oners to further informa5on

What is the background to

AWAGs recommenda5ons?
Weekly CICO training on
live anaesthetised,
critically hypoxic sheep
has occurred in Western
Australia since 20022
Dr Heard and team have
observed over 10 000
attempts at Percutaneous
Emergency Oxygenation
(PEO) by anaesthetists

Background
This model informed the
development of a CICO
algorithm, which has become
popular in Australia3

SHEEP

CICO

Oxygenate and stabilise

Oxygenate and stabilise

Oxygenate and stabilise

What are the principles behind

the algorithm?
Emergency
reoxygenation
(c.f. ventilation)

Techniques
tailored to the
skills of
anaesthetists

Conversion to
cuffed airway
once critical
hypoxia resolved

Principles behind the algorithm

It encourages attempts at both
cannula and scalpel in a logical
order, least invasive first

AWAGs posi5on on CICO

AWAG recommends the Australian CICO
algorithm
We recommend hospitals provide regular
training for anaesthe@sts in the PEO
techniques, and the immediate availability of
the equipment
AWAG is aFemp@ng to standardise this
approach throughout Wales

2015 DAS Plan D

What is the key dierence

between DAS and AWAG
recommenda5ons?
DAS = scalpel only

AWAG = cannula rst

Scalpel only
Experience in wet lab shows: If
scalpel fails, blood in airway
limits success of subsequent
cannula attempts (loss of air
aspiration end-point)

Blood and tissue destruction

also limits subsequent
scalpel attempts (in
anaesthetists hands)

Scalpel only

Thus scalpel first =

scalpel only

Cannula rst
Experience in wet lab
shows: failed cannula
attempt does not limit
success of subsequent
scalpel attempts
Failed cannula does not
significantly limit success of
subsequent cannula attempts
either
Failed cannula is identified
quickly (no air aspirated)
multiple attempts possible,
quickly

Cannula rst
Both cannula and surgical can be successful
with correct equipment and technique
Both can fail too
It makes sense for anaesthe@sts to try both if
necessary
This can only reliably be done with cannula
first

Are Human Factors relevant here?

Most anaesthe@sts would choose cannula
rather than surgical when faced with CICO4,5
Permission to use cannula rst always, may
aid transi@on to CICO

Transi5on to CICO
Cricothyroid membrane (CTM) is dicult or
impossible to palpate in the majority of
human CICO scenarios6
DAS Plan D requires anaesthe@st to make a
decision about type of surgical technique at
the point of transi@on to CICO, based on CTM
palpability
Experience from Wet Lab is that Analysis
paralysis can impede transi@on to CICO

But doesnt NAP4 prove that

surgical is beDer?
100% success
Surgical incision

puncture

37%
Narrow-bore cannulaover-needle
Wide-bore cannula-overtrocar
Seldinger

57%

NAP4

Vs

NAP4
All surgical aFempts in NAP47 were performed
by head and neck surgeons
NAP4 does not give any data on the success or
failure of surgical techniques in the hands of
anaesthe@sts, as no anaesthe@st chose
surgical

How about the other studies

suppor5ng surgical approach?
Lockey et al.8 Hubble et
al.9 , Mabry10

None gives data on

anaesthetists in a
CICO scenario
(prehospital/military)

How about the other studies

suppor5ng surgical approach?
and the surgical techniques
used in these papers are
different to the scalpel-bougie
technique
Wet lab experience
shows that success
with one surgical
technique success
with another

Ok. But isnt jet ven5la5on

dangerous?
Yes. Attempting to ventilate
with a high pressure source via
a cannula can be dangerous.

Especially if using a
ManujetTM.

Ok. But isnt jet ven5la5on

dangerous?
However we recommend jet
OXYGENATION using Rapid-O2TM
safety profile much better see Ref
3 for more details

So does AWAG suggest avoiding

the scalpel-bougie technique
altogether?
No. Dr Heard developed the
SB in the Wet Lab and
described it at DAS 2005
Its indication is 3 failed
cannula attempts (or 60
seconds elapsed), and
palpable CTM or trachea

CICO

Oxygenate and stabilise

Oxygenate and stabilise

Oxygenate and stabilise

Is the DAS scalpel-bougie

technique the same as that
recommended by AWAG?

We recommend seeking
endpoints to determine
successful bougie insertion

Is the DAS scalpel-bougie

technique the same as that
recommended by AWAG?
For example seeking clicks
on tracheal rings

and oxygenating via the bougie to

provide life-saving reoxygenation
and early identification of
peritracheal placement (via
capnography)

Guidance for when the CTM is

impalpable
The 2015 DAS guidelines recommend a long
incision if the CTM is impalpable.
However the scalpel-bougie
(and cannula techniques)
are applicable via the
trachea as well as CTM3

We do not recommend a
long incision if the trachea
is palpable

What are AWAGs

recommenda5ons when the CTM
and trachea are impalpable?
Dr Heard developed recommenda@ons for
this, using a fat neck live sheep model, in
2005
It involved 6 months of trial and error, and
ENT input

Fat Neck recommenda5ons:

AFempt percutaneous cannula (i.e. cannula
rst EVERY @me, aids transi@on to CICO)
Aided by ultrasound localisa@on of trachea (if
IMMEDIATELY) available
scalpel-nger-cannula if cannula fails (long
midline incision, blunt dissec@on, stabilise
trachea, cannula tracheotomy - see REF 3)

Fat Neck recommenda5ons:

Dr Heard evaluated the scalpel-nger-
bougie (which DAS recommends if CTM not
palpable) in the fat neck live sheep model in
2005.
(long midline incision, blunt dissec@on,
stabilise trachea, perform scalpel-bougie)
He found it has a very low success rate in a
deeply placed trachea:

Scalpel Bougie
Thin neck

Bougie needs to be held

horizontally in order for the
coud tip to pass along the
blade and into the airway

Scalpel Finger Bougie

In a fat neck, aeer the
long midline incision
the trachea is at the
boFom of a valley of
@ssue, lling with blood
The sheer sides prevent
the bougie being held
horizontally, thus the
coud @p misses the
airway
Gap

Fat neck

Scalpel Finger Bougie

Thin neck

Fat neck

Gap

Do AWAGs recommenda5ons
have any DAS support?
Yes. There is explicit support in the
guidelines paper:

There are, however, other valid

techniques for front-of-neck access,
which may continue to be provided
in some hospitals where additional
equipment and comprehensive
training programmes are available.1

 There is further support in DAS response to

AWAGs correspondence to the BJA:
We would like to make it clear that
the 2015 guidelines do not exclude
the use of other rescue
techniques...11

http://bja.oxfordjournals.org/content/
115/6/827.short/reply#brjana_el_13473

the guidelines recognise that it is

reasonable for individuals who are
appropriately trained in alternative
techniques to use them;(such as)
the protocolised rescue oxygenation
techniques described and taught by
Heard et al.11

Do AWAGs recommenda5ons
have any DAS support?
So AWAG is con@nuing to promote the
Australian CICO algorithm in Wales, alongside
helping departments set up regular training
and equipment requirements.

How do I nd out more?

View a summary of the algorithm and
techniques12
Read a comprehensive guide to managing
the CICO scenario3
Watch videos of the PEO techniques13
AFend CICO training*
*contact david.lacquiere@wales.nhs.uk for details of your nearest training centre

Apnoeic
oxygena5on
References
1.
2.
3.
4.

Frerk C, Mitchell VS, McNarry AF, et al. Dicult Airway Society 2015 guidelines for management of unan@cipated dicult intuba@on
in adults. Br J Anaesth 2015; 115: 827-48
Heard AMB, Green RJ, Eakins P. The formula@on and introduc@on of a cant intubate, cant ven@late algorithm into clinical prac@ce.
Anaesthesia 2009; 64: 6018
Heard A. Percutaneous Emergency Oxygena@on Strategies in the Cant Intubate, Cant Oxygenate Scenario. Smashworks Edi@ons;
2013. Available from hFps://www.smashwords.com/books/view/377530 (accessed 22 December 2015)
Wong DT, Lai K, Chung FF, Ho RY. Cannot intubate-cannot ven@late and dicult intuba@on strategies: results of a Canadian na@onal
survey. Anesth Analg 2005; 100: 1439-46

5.

Wong DT, Mehta A, Tam AD, Yau B, Wong J. A survey of Canadian anesthesiologists preferences in dicult intuba@on and cannot
intubate, cannot ven@late situa@ons. Can J Anaesth 2014; 61: 717-26

6.

Heard C, Heard A, Dinsmore J. How dicult is it to iden@fy anterior neck airway structures in the CICV scenario? Poster presented at
2012 American Society of Anesthesiologists mee@ng, Washington DC, USA. www.asaabstracts.com/strands/asaabstracts/
abstract.htm;jsessionid=2497AF213745589CA7F2F3860C5577B4?year=2012&index=15&absnum=3611 (Accessed 22 December
2015)
4th Na@onal Audit Project of The Royal College of Anaesthe@sts and The Dicult Airway Society. Major complica:ons of airway
management in the United Kingdom, Report and Findings. Royal College of Anaesthe@sts, London, 2011
Lockey D, Crewdson K, Weaver A, Davies G. Observa@onal study of the success rates of intuba@on and failed intuba@on airway
rescue techniques in 7256 aFempted intuba@ons of trauma pa@ents by pre-hospital physicians. Br J Anaesth 2014; 113: 2205
Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II:
alterna@ve airway devices and cricothyrotomy success rates. Prehosp Emerg Care 2010; 14: 51530
Mabry RL. An analysis of baFleeld cricothyrotomy in Iraq and Afghanistan. J Spec Oper Med 2012; 12: 1723
Response to Dr Heard and Dr Lacquiere hFp://bja.oxfordjournals.org/content/115/6/827.short/reply#brjana_el_13473 (accessed
22 March 2016).
Lacquiere D. Emergency Percutaneous Airway challenges and solu@ons. hFps://learnataagbi.org/video/play/336 (accessed
23/03/16).
hFps://www.youtube.com/user/DrAMBHeardAirway (accessed 23/03/16).

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